Knowledge, Perception, and Associated Factors of Electronic Cigarette Consumption Among the Saudi Population in Jeddah City

Introduction Electronic cigarettes (e-cigarettes) are rising in popularity among young adults and teenagers. Previous studies have shown that among high and middle schoolers, the percentage of e-cigarette smokers was noticeably higher than tobacco cigarette smokers. Various research papers focusing on different communities have reported a low-to-moderate level of knowledge and awareness of e-cigarette’s effects on health. E-cigarettes were initially advertised as devices to help people quit smoking, but the use of e-cigarettes in modern days has changed considerably. A big chunk of the population perceived that e-cigarettes have no harmful effects because they are nicotine-free and thus are used as a replacement for regular cigarettes rather than as a way to quit smoking. Objectives The study aimed to assess the perception of e-cigarette consumption and associated factors among the Saudi population in Jeddah city. Methodology A cross-sectional study was conducted on the Saudi population in Jeddah, Saudi Arabia, during the year 2023. The study assessed the participant’s perceptions of e-cigarette consumption and its risk factors. A pre-existing online questionnaire created by Google Forms was distributed among the population through social media applications to collect data after obtaining their informed consent. Results A total of 515 participants were included in this study. Relatives and friends were the most common sources (54%) for information about e-cigarettes. Of the sample, 17.5% thought that e-cigarettes were safer than conventional cigarettes, 13.4% used e-cigarettes on a regular basis, and 65% had not smoked electronically before. Vaping pushed only 17.2% to try traditional tobacco cigarettes, and 25% stopped using traditional tobacco products after starting to smoke e-cigarettes. Gender, age group, and total family salary were the associated factors with the use of e-cigarettes. In addition, an association between the perception of e-smoking and its use was noticed, as well as a significant association between gender and withdrawal symptoms. Conclusion A minority of the participants perceived that e-cigarette smoking is safer than conventional methods of smoking. The majority did not practice e-smoking at all. Furthermore, results showed that relatives and friends were the most common sources of information. The findings from the correlation testing underscore several noteworthy associations within the studied population. Notably, gender, age, total family salary, and occupation exhibited statistically significant correlations with e-cigarette usage.


Introduction
Electronic cigarettes are rising in popularity among young adults and teenagers.Previous studies have shown that among high and middle schoolers, the percentage of e-cigarette smokers was noticeably higher than tobacco cigarette smokers.Various research papers focusing on different communities have reported a low-to-moderate level of knowledge and awareness of e-cigarette's effects on health.E-cigarettes were initially advertised as devices to help people quit smoking, but the use of e-cigarettes in modern days has changed considerably.A big chunk of the population perceived that e-cigarettes have no harmful effects because they are nicotine-free and thus are used as a replacement for regular cigarettes rather than as a way to quit smoking.

Objectives
The study aimed to assess the perception of electronic cigarette consumption and associated factors among the Saudi population in Jeddah city.

Methodology
A cross-sectional study was conducted on the Saudi population in Jeddah, Saudi Arabia, during the year 2023.The study assessed the participant's perceptions of electronic cigarette consumption and its risk factors.A pre-existing online questionnaire created by Google Forms was distributed among the population through social media applications to collect data after obtaining their informed consent.

Results
A total of 515 participants were included in this study.Relatives and friends were the most common source (54%) for information about electronic cigarettes.Of the sample, 17.5% thought that e-cigarettes were safer than conventional cigarettes, 13.4% used e-cigarettes on a regular basis, and 65% had not smoked electronically before.Vaping pushed only 17.2% to try traditional tobacco cigarettes, and 25% stopped using traditional tobacco products after starting to smoke e-cigarettes.Gender, age group, and total family salary were the associated factors with the use of e-cigarettes.In addition, an association between perception about e-smoking and its use was noticed, as well as a significant association between gender and withdrawal symptoms.

Conclusion
A minority of the participants perceived that electronic cigarette smoking is safer than conventional methods of smoking.The majority didn't practice e-smoking at all.Furthermore, results showed that relatives and friends were the most common source of information.The findings from the correlation testing underscore several noteworthy associations within the studied population.Notably, gender, age, total family salary, and occupation exhibited statistically significant correlations with electronic cigarette usage.

Introduction
Tobacco use and abuse are considered significant global public health issues [1].Tobacco smoke can cause severe health issues, including cancer and other serious illnesses because it is loaded with over 7,000 poisonous substances [2].Many people still smoke or use tobacco products despite the widely recognized health hazards associated with tobacco use [3].
The electronic cigarette, (e-cigarette), is a rechargeable battery-powered device that is designed to mimic the sensation of smoking a real cigarette by producing vaporized nicotine that simulates cigarette smoke [4].It also produces an aerosol that contains fewer toxicants than tobacco smoke.However, prolonged exposure to e-cigarette vapor may lead to nicotine dependence and, consequently, an increased risk of respiratory and cardiovascular health effects [5].
E-cigarettes are thought to have been first introduced into the United States tobacco market in 2007, and despite being advertised as a product to aid in smoking cessation, they captured astonishing numbers of young consumers [6].Throughout the last 10 years, e-cigarettes have gained much popularity among high school and middle school students as the main source of nicotine consumption [6].In 2019, a cross-sectional observational study conducted on 19,018 high and middle school students concluded that 27.5% of the high school students surveyed were e-cigarette users, as opposed to 5.8% reporting conventional tobacco cigarette use.Among middle school students, usage rates were 10.5% and 2.3% for current e-cigarettes and conventional tobacco cigarettes, respectively [7].
In a study from Saudi Arabia, 467 participants who were first-year university students in Riyadh aged between 18 and 24 years showed moderate awareness of the harmful effects of e-cigarettes [8].Another study conducted in Al-Ahsa, involving 325 participants through a cross-sectional survey of adult male smokers, has shown that the level of knowledge and awareness was high [9].In a study published in 2022 among the teaching and non-teaching members of King Saud bin Abdulaziz University, the results showed the majority of 337 participants had little knowledge and attitudes toward e-cigarettes [10].A study among 507 undergraduate students in Thailand showed a lack of knowledge about e-cigarettes' harmful effects [11].
The use of e-cigarettes is changing, and there's still a lot we don't know about it.The tobacco industry is targeting young adults and promoting their brands as a way to quit regular cigarettes, even though we're not sure about the long-term health effects of e-cigarettes.Most of the research on this topic in Saudi Arabia has focused on medical students, but we're interested in studying the young population and their awareness, associated factors, attitudes, and use of e-cigarettes.Such findings could help regulators make stricter rules.We also want to find out whether adults who only use e-cigarettes are likely to start smoking regular cigarettes.We don't have much evidence about e-cigarette use, its connection to regular smoking, or the factors that influence e-cigarette use in Saudi Arabia.Because it's important to control tobacco use and find safer alternatives, we need to investigate these issues in Saudi Arabia.The World Health Organization considers e-cigarettes toxic and as a way for kids and teens to start smoking, so it's imperative to know how many people are using e-cigarettes and to understand public opinion.The most recent study in Jeddah was done in 2019.

Study Design
We conducted a cross-sectional survey to assess the perception of electronic cigarette consumption and associated factors among the Saudi population in Jeddah city, Saudi Arabia.We used an online questionnaire through Google Forms to gather responses.Participation was voluntary, and the participants' identities remained anonymous.

Study Setting
The study took place in Jeddah, Saudi Arabia, from October to November in 2023.It focused on the consumption of electronic cigarettes and associated factors among adults living in the city.Ethical approval was obtained at the University of Jeddah (approval no.UJ-REC-166).The consent form was printed on the first page of the questionnaire and stated that by submitting the questionnaire the subject agreed to participate in the study.All information was kept confidential and used only for the purposes of scientific research.

Inclusion and Exclusion Criteria
The inclusion criteria of this study were adult males and females, above 18 years old, living in Jeddah, who were electronic cigarette smokers.Smokers from outside Jeddah city, conventional cigarette smokers, and non-current smokers, The study excluded who refused to be participate, or had any of the following conditions: psychiatric issues, or were outside the target age range.

Sample Size
According to the online calculator (http://www.raosoft.com/samplesize.html),a sample size of at least 384 is required to accurately represent the population with a 5% margin of error and a 95% confidence level.

Methods for Data Collection and Instrument
A Google Forum E-questionnaire that was distributed among a sample size of 515 participants, appropriate for the latest 2022 Jeddah Census, provided the means for data collection.The questionnaire is a modified version of a pre-existing published questionnaire [12].The original authors granted permission for the distribution of their questionnaire for the purposes of this research.

Measures
We used the Statistical Package for the Social Sciences (SPSS) to assess the percentage of individuals who were aware of or who used e-cigarettes, the percentage of individuals who stopped traditional smoking habits upon transitioning to vaping, and the percentage of individuals who initiated traditional smoking after beginning the use of e-cigarettes.

Outcome Variables
Outcome variables included the awareness and Associated factors of e-cigarettes among the general population, the percentage of e-cigarette users within the population, the percentage of individuals who successfully quit smoking as a result of vaping, and the percentage of people who started traditional smoking after starting to vape.

Analyses and Entry Method
The data will be inputted into a computer using the Microsoft Office Excel software (2016) application designed for Windows.Subsequently, the data will be transferred to the SPSS application for the purpose of conducting statistical analysis (IBM SPSS Statistics for Windows version 20.0, Armonk, NY: IBM Corp.).

Results
This study was conducted among the Saudi population in Jeddah city; after excluding participants from outside Jeddah city, a total of 515 participants were included in the study.The percentage of males was lower than females (42.7% and 57.3%) respectively.The most common age group was 18-24 years (54.2%).Almost half the participants had a bachelor's degree (52.2%).The total family salary was less than 75.000SR per year in 27.6%.Regarding occupation, students constituted (50%) of all respondents, followed by employees at 32.6% (Table 1).This study included only participants who had heard about electronic smoking and cigarettes previously.The results showed that relatives and friends were the most common source for information about electronic cigarettes (54%) followed by social media platforms (39.2%; Figure 1).Many (71.1%) thought the sale and purchase of electronic cigarettes is legal and allowed in Saudi Arabia; 44.5% though that 18 years old is the minimum age requirement for using electronic cigarettes, whereas (19.8%) agreed that electronic smoking is prohibited for all age groups, and (86%) agreed that electronic smoking should be banned in enclosed places or in places where smoking is prohibited, such as workplaces, restaurants, cafes, and cinemas (Table 2).

Variables Frequency Percentage
A small percentage (5.2%)believed that electronic smoking is safer than nicotine patches or nicotine gum; 6.8% thought that electronic cigarettes only emit water vapor; 17.5% thought that they are safer than conventional cigarettes and tobacco products, and the source of this information was social media in 28% of cases.Most (70.5%) agreed that electronic cigarettes contain dangerous chemicals, but 11.8% believed that the preservatives and flavors used in electronic cigarettes are harmless.Only 4.3% believed that exposing children to the use of electronic cigarettes is safe, and 56.5% believed that the concentrated nicotine solution in some cartridges or packaging can cause death if swallowed or consumed by a child.Most (79%) thought that electronic smoking in enclosed spaces causes harm to nonsmokers nearby (passive smoking), and only 7.4% considered electronic smoking to be safer for pregnant women and their fetuses.A majority (62.7%) of the participants had family members or friends who practiced electronic smoking (Table 3).
A total of 69 (13.4%) used electronic cigarettes or smoked electronically on a regular basis, whereas 61 (11.8%) did so occasionally, and 65% had not smoked electronically before (Figure 2).Almost half (47.5%) used electronic cigarettes more than once a day ( Figure 3).
Ease of use was the most common reason that the participants used electronic cigarettes (62.8%).The fourth generation of electronic cigarettes was the most popular type (48.8%).More than half (55.6%) bought electronic cigarettes from tobacco and shisha shops, and 51.1% trusted the nicotine concentration value written on the product's label.Most of participants (66.3%) vaped indoors and outdoors (Table 4).4).A small minority (8.3%) had not experienced any withdrawal symptoms because they had not stopped vaping, whereas 36.7% hadn't experienced any withdrawal symptoms even though they had stopped vaping for a while (Table 5).
A few (6.7%) participants went to the emergency department or were admitted to a hospital because of a condition related to vaping; the most common cause of admission was difficulty breathing (30%; Table 6).

Answer Frequency Percentage
Yes, I experienced withdrawal symptoms.145 78.9% No, I haven't experienced any withdrawal symptoms because I haven't stopped vaping.14 3.9% No, I haven't experienced any withdrawal symptoms even though I stopped vaping for a while.62 17.1%  Of the participants who smoked, 84.7% experienced symptoms after vaping; the most common symptoms were cough (27.5%), dizziness (24.2%), and respiratory irritation (23.6%; Figure 5).Results showed that 38.9% hadn't used traditional tobacco cigarettes (Table 7).Vaping pushed only 31 (17.2%) to try and use traditional tobacco cigarettes (Figure 6), whereas (25%) of participants no longer used traditional tobacco products after starting to smoke electronic cigarettes, and 15% reduced their use of traditional tobacco products since they started vaping (Figure 7).Correlation testing revealed a statistically significant association between gender, age, total family salary, occupation of participants, and the use of electronic cigarettes (P < .05;Table 8).In addition, Table 9 shows the association between beliefs about e-smoking and its use, where (P < .05) is a significant association.Conversely, Table 10 illustrates a significant association between gender and withdrawal symptoms (P value < .05).No other variables were significantly associated with the smoking of electronic cigarettes (P value > .05;Tables 11,12).

Discussion
The consequences of e-cigarette use for public health have attracted considerable debate and interest.Evidence-based data about the rate of e-cigarette awareness and use are limited to a few countries [13][14].However, several previous studies reported a significant increase in awareness and use of e-cigarettes recently [15][16].Currently, national data on the perception and use of e-cigarettes among the Saudi population are limited, and the research that has been conducted primarily focused on traditional methods of tobacco smoking.There is a need to identify what the public perceives and believes about e-cigarettes, as well as who uses e-cigarettes.Accordingly, the current study was conducted to investigate the perception of Saudi population in Jeddah toward e-cigarettes.
A total of 515 participants were included in the study, out of which more than half were females (57.3%).The most common age group was 18-24 years old (54.2%).This may be explained by the curiosity of youth toward new devices and their higher use of the internet and social media where e-cigarettes are marketed and advertised.
Regarding sources of knowledge about e-cigarettes, results showed that relatives and friends were the most common source of information (54%) followed by social media platforms (39.2%).Similarly, the most common sources reported in previous studies [17] were the internet, friends or personal contacts, and advertisements.Furthermore, a previous study found that older people and lower education groups were more likely to hear about e-cigarettes from television whereas the internet was the main source of knowledge among younger people and higher education groups [18].
Almost half the participants (44.5%) considered that 18 years old is the minimum age requirement for using electronic cigarettes, whereas 19.8% agreed that electronic smoking is prohibited for all age groups.In a previous study, it was noticed that younger respondents were more aware of e-cigarettes than older respondents; the highest percentage of awareness (42.3%) was among the group aged 15-24 years whereas the lowest percentage (6.8%)was among those aged ≥ 55 years [19].
Only 5.2% believed that electronic smoking is safer than nicotine patches or nicotine gum, whereas 17.5% assumed that they are safer than conventional cigarettes and tobacco products.This is compatible with the results of a previous study, in which more than one-third of those who are familiar with e-cigarettes (41.6%) thought that e-cigarettes aid in smoking cessation.Meanwhile, 31.9% believed that e-cigarettes are less harmful than traditional cigarettes, and 5.6% reported that e-cigarettes are not harmful at all [18].In addition, 86% agreed that electronic smoking should be banned in enclosed places or in places where smoking is prohibited, such as workplaces, restaurants, cafes, and cinemas, because electronic smoking in enclosed spaces causes harm to nonsmokers nearby (passive smoking).
Regarding the practice of e-smoking, 69 (13.4%) used an electronic cigarette or smoked electronically on a regular basis, whereas 61 (11.8%) did so occasionally.Of these, 47.5% used electronic cigarettes more than once a day.Ease of use was the most common reason participants were attracted to electronic cigarettes (62.8%).The fourth generation of electronic cigarettes was the most popular type (48.8%), and 51.1% trusted the nicotine concentration value written on the product's label.However, (78.9%) experienced withdrawal symptoms after electronic cigarette use, and the most common withdrawal symptoms were anger and agitation (29.6%), nicotine urges (29%), fatigue (21.3) anxiety (22.5%), lack of patience (19.5%), and difficulty in concentration (18.9%).It is not surprising that most people think e-cigarettes are safer than traditional cigarettes because of the deceptive marketing of the competitive advantages of e-cigarettes over traditional cigarettes.
The findings from the correlation testing underscore several noteworthy associations within the studied population.Notably, gender, age, total family salary, and occupation exhibited statistically significant correlations with electronic cigarette usage (P < .05).Furthermore, beliefs regarding e-smoking and its use demonstrated a significant association (P < .05).Interestingly, a noteworthy link between gender and withdrawal symptoms, signifying a statistically significant relationship (P < .05),was observed.These results shed light on the multifaceted interplay among demographic factors, beliefs, and health outcomes in the context of electronic cigarette usage.
Based on the findings of this study, we recommend that serial and frequent studies on e-cigarettes should be conducted and funded to generate more evidence and data regarding this topic.Educational campaigns, medical missions, and media recruitment should be held to increase community awareness of this issue, and

FIGURE 6 :FIGURE 7 :
FIGURE 6: Did Vaping Push You to Try Traditional Tobacco Cigarettes When You Hadn't Used Them Before?

TABLE 1 : Sociodemographic Characteristics of Study Participants, Jeddah City, (N = 515) FIGURE 1: Methods of Hearing or Learning About Electronic Cigarettes Among Participants, Jeddah City, (N = 515) Variable Answer Frequency Percentage
Do you think the sale and purchase of electronic cigarettes is legal and allowed in Saudi Arabia?

TABLE 5 : Prevalence of Withdrawal Symptoms After Electronic Cigarettes Use FIGURE 4: Prevalence of Withdrawal Symptoms After Electronic Cigarettes Use Among Participants, Jeddah City, (N = 145) Variable Answer Frequency Percentage Have
you ever gone to the emergency department or been admitted to a hospital because of a condition related to vaping?

TABLE 6 : Percentage of Participants Admitted to Hospital Because of a Condition Related to Vaping; Causes of Admission, Jeddah city, (N=180) FIGURE 5: Symptoms Experienced After Vaping, Jeddah City (N=354)
I'm a dual user; I use both traditional cigarettes and electronic cigarettes.